Victor Figueroa

Critical Outcome Analysis of Staged Buccal Mucosa Graft Urethroplasty for Prior Failed Hypospadias Repair in Children

PURPOSE Although staged buccal mucosa graft urethroplasty is a well accepted technique for salvage urethroplasty, there are few reports on this procedure for redo hypospadias repair in children. MATERIALS AND METHODS We reviewed patients who underwent staged buccal mucosa graft urethroplasty for redo hypospadias repair. Age, quality of graft before tubularization, meatal position, presence of balanitis xerotica obliterans and complications were recorded. RESULTS A total of 30 patients underwent 32 repairs during a 5-year period. Mean age at first stage was 7 years (range 1 to 17) and mean interval between stages was 9.3 months (5 to 13). Mean followup after second stage was 25 months (range 10 to 46). Meatal position before first stage was proximal in 44% of patients, mid shaft in 39% and distal in 16%. Nine patients had biopsy proved balanitis xerotica obliterans. There were no donor site complications. Four patients underwent a redo grafting procedure. Complications after second stage occurred in 11 of 32 repairs (34%), consisting of urethral stenosis in 5, glanular dehiscence in 3 and urethrocutaneous fistula in 3. A third of the patients had some degree of graft fibrosis/induration after the first stage. These patients were prone to more complications at second stage (9 of 11, 82%), compared to patients without these unfavorable findings (4 of 21, 19%; p<0.001). Presence of balanitis xerotica obliterans and meatal position were not significant factors associated with adverse outcomes. CONCLUSIONS Staged buccal mucosa graft urethroplasty is a suitable technique for salvage urethroplasty. Complications after second stage were seen in approximately a third of patients, mainly those with fibrotic/indurated grafts.

Nephron Sparing Surgery for Unilateral Wilms Tumor in Children with Predisposing Syndromes: Single Center Experience Over 10 Years

PURPOSE Unilateral Wilms tumors associated with predisposing syndromes are treated with preoperative chemotherapy followed by surgical resection. We describe our experience with nephron sparing surgery for Wilms tumor in this population at risk for metachronous lesions. MATERIALS AND METHODS We conducted a retrospective review of all children with a predisposing syndrome who underwent nephrectomy for malignancy during a 10-year period (2000 to 2010). Data collected included age, mode of detection, tumor size, treatment, pathology results, followup time and recurrence episodes. RESULTS From 2000 to 2010, 13 of 75 (19%) patients treated for Wilms tumor were diagnosed with predisposing syndrome(s). Eight patients with unilateral tumors were treated and had a mean age at diagnosis of 27 months (range 7 months to 9 years). Beckwith-Wiedemann syndrome, isolated hemihyperplasia, WAGR (Wilms tumor, Aniridia, Genitourinary abnormalities, mental Retardation) syndrome and isolated 11p13 deletion were the underlying diagnoses in 3, 2, 2 and 1 patient, respectively. All but 2 patients were diagnosed by screening ultrasound and 5 underwent preoperative chemotherapy. Median tumor size at surgery was 2.5 cm (range 1 to 13). Nephron sparing surgery was performed in 6 of 8 patients. Pathological study showed favorable histology Wilms tumor and nephrogenic rests in 6 and 2 patients, respectively. After a mean followup of 36 months (range 6 to 72) no recurrences were documented and all children had normal creatinine levels. CONCLUSIONS Nephron sparing surgery appears safe for patients with unilateral Wilms tumor associated with predisposing syndrome(s), allowing for the preservation of renal function and good oncologic outcomes for the available followup time. If more studies confirm our observation, current recommendations for the surgical treatment of Wilms tumor may need to reemphasize the value of attempting nephron sparing surgery in this patient population.

Failed Pyeloplasty in Children: Revisiting the Unknown

OBJECTIVE To perform a critical analysis of the management of the pediatric failed pyeloplasty in a large tertiary center. The ideal approach to this rare entity is not well established. METHODS Retrospective record review of children undergoing pyeloplasty from 2000 to 2010. All cases that required any type of reintervention, excluding stent removal, were analyzed. Data collected included: demographics, indication for and modality of the initial surgery, presence of crossing vessels, mode of diagnosis of failure, and type(s) of reintervention with the correspondent success rate(s). RESULTS Overall, pyeloplasty failure rate was 27 per 455 patients (5.9%). Age, initial indication for pyeloplasty, and modality of surgery (open vs laparoscopic) yielded similar failure rates. Indications for reintervention were as follows: worsening asymptomatic hydronephrosis 16 of 27 (59%), pain 7 of 27 (26%), urosepsis 2 of 27 (7.5%), and others 2 of 27 (7.5%). Eight of 27 (30%) improved with 1, 14 of 27 (52%) had 2, and 5 of 27 (18%) required 3 reinterventions, respectively. Mean interval between the first operation and subsequent interventions was 19.3, 24.9, and 27 months for the first, second, and third reinterventions, respectively. Modalities of reintervention with respective success rates were as follows: double J stent insertion 16% (6%), endopyelotomy 18% (50%), redo pyeloplasty 12% (92%), and ureterocalicostomy 4% (100%). Only 1 patient (7%) was documented to have a missed crossing vessel. All patients were stable and doing well after a mean follow-up of 56 months after the first operation. CONCLUSION According to this series, more invasive and definitive techniques, such as redo pyeloplasty and ureterocalicostomy, are more successful than minimally invasive ones to treat failed pyeloplasty and should probably be offered sooner rather than later.

Comparative Analysis of Detorsion Alone Versus Detorsion and Tunica Albuginea Decompression (Fasciotomy) with Tunica Vaginalis Flap Coverage in the Surgical Management of Prolonged Testicular Ischemia

PURPOSE Recent data suggest that testicular torsion may include an element of the compartment syndrome that improves with decompression. In 2009 we instituted tunica albuginea incision with tunica vaginalis flap coverage as an alternative in cases in which the torsed testis continued to appear ischemic after detorsion. MATERIALS AND METHODS The medical records of 65 boys who underwent scrotal exploration for testicular torsion between 2000 and 2010 were reviewed. There were 6 patients excluded from study due to lack of followup. Of the remaining 59 patients 31 (52.5%) showed improvement in testicular appearance after detorsion and underwent orchiopexy, whereas 28 (47.5%) did not show evidence of recovery after detorsion. Of these patients 11 underwent tunica albuginea incision with tunica vaginalis flap coverage and 17 underwent orchiectomy. Demographic data, duration of symptoms and rate of testicular salvage were analyzed. RESULTS Mean patient age was 11.8 years (detorsion plus orchiopexy), 10.1 years (tunica albuginea incision plus tunica vaginalis flap coverage) and 10.1 years (detorsion plus orchiectomy). Average followup was greater than 6 months in all groups. Mean duration of torsion was 13.4 hours (detorsion plus orchiopexy), 31.2 hours (tunica albuginea incision plus tunica vaginalis flap coverage) and 67.5 hours (detorsion plus orchiectomy). Before tunica albuginea incision with tunica vaginalis flap coverage was offered, the rate of orchiectomy was 35.9% (14 of 39) vs 15% (3 of 20) after this technique was introduced (p <0.05). The rates of testicular salvage were 62.5% (detorsion plus orchiopexy), 54.6% (tunica albuginea incision plus tunica vaginalis flap coverage) and 0% (detorsion plus orchiectomy). Although the numbers are limited, it is likely that without tunica albuginea incision with tunica vaginalis flap coverage 6 of 11 testes would have been removed. CONCLUSIONS This preliminary experience suggests that tunica albuginea incision with tunica vaginalis flap coverage is a promising option for the management of clinically marginal torsed testes, enhancing salvageability after prolonged ischemia. We recommend considering this maneuver before performing orchiectomy in selected cases of testicular torsion.

Single-center experience with botulinum toxin endoscopic detrusor injection for the treatment of congenital neuropathic bladder in children: Effect of dose adjustment, multiple injections, and avoidance of reconstructive procedures

OBJECTIVE Since 2007, intra-detrusor OnabotulinumtoxinA (OnabotA) injections have been selectively offered at our institution for cases in which maximal anticholinergic therapy failed or was not tolerated. Herein we present our experience with this approach. MATERIALS AND METHODS We prospectively obtained data on 17 patients who underwent OnabotA injections over a 4-year period. Demographic information, number of injections, and dose delivered were captured. Children were monitored with baseline and post-injection renal ultrasound, urodynamics, and assessed for side effects, satisfaction, and symptom improvement. RESULTS Forty-three sessions were performed with injections given every ∼ 6 months. Mean patient age was 10.7 years (range, 3-17). Compared with baseline, after the first injection, mean bladder capacity adjusted for age and compliance improved by 27% (p = 0.039) and 45.2% (p = 0.041), respectively. After subsequent injections, these values increased to 35.7% (p = 0.043) and 55.1% (p = 0.091), respectively. Out of 13 symptomatic patients, ≥ 50% improvement was reported in ten (76.9%) and complete resolution in seven (53.8%). However, all three patients in whom the maximum dose of OnabotA was reduced from 300 to 200 units complained of recurrent symptoms. Fourteen children avoided surgical reconstruction as a second line of treatment. Overall patient/parental reported satisfaction rate was 70.6% (12/17). CONCLUSIONS Intra-detrusor OnabotA injection is a promising intervention for management of neuropathic bladder in selected patients. Our data demonstrate improvement in symptoms and urodynamic parameters. Although an optimal dose has not been determined for children, we found optimal response with a maximum administration of OnabotA up to 300 units.

Laparoscopic ureteral ligation (clipping): A novel, simple procedure for pediatric urinary incontinence due to ectopic ureters associated with non-functioning upper pole renal moieties

OBJECTIVE A simplified approach for the surgical management of symptomatic ectopic ureters, associated with a non-functioning upper moiety, with laparoscopic ureteric clipping is presented in this research paper. MATERIALS AND METHODS Prospectively collected data on nine consecutive girls with ectopic ureters associated with urinary incontinence who underwent laparoscopic clipping between February 2011 and December 2013. Surgical technique consisted of cystoscopy and insertion of ureteral catheter in the lower pole ureter to aid in identification and clipping of the ectopic ureter, which was achieved by standard trans-peritoneal laparoscopy. RESULTS Median age was eight years (range 4-17 years). Diagnosis was based on clinical findings, which were supported by: ultrasound (US), nuclear scans and magnetic resonance urography in Cases 9, 8 and 5, respectively. Bilateral complete duplication was present in two patients; the combination of cystoscopy and laparoscopy allowed adequate identification of the ectopic ureter causing incontinence in both. All nine patients were immediately dry after surgery and remain asymptomatic after a maximum follow up of 27 months. Eight out of nine patients had developed some degree of asymptomatic upper pole hydronephrosis on follow-up US. CONCLUSION Laparoscopic clipping holds promise as a simple alternative to other more-complex surgical procedures in the treatment of incontinence due to an ectopic ureter. Despite favorable and encouraging initial results, further follow up is warranted in order to determine the fate of expected associated upper-pole hydronephrosis.

Intraoperative management and early postoperative outcomes of pediatric renal transplants

Smaller children are presenting for renal transplantation as the treatment of choice for end‐stage renal disease. Adult donor organs are more successful than pediatric deceased donor organs. An adult kidney may sequester ~75% of the circulating volume of a 5 year‐old child and requires significantly increased cardiac output to maintain renal perfusion. Treatment includes volume, inotropic or vasopressor agents, or central neuroaxial blockade for sympatholysis.

Glans amputation during routine neonatal circumcision: Mechanism of injury and strategy for prevention

OBJECTIVE Glans injury during circumcision is an uncommon yet potentially devastating complication. Its mechanism remains poorly understood. Herein we critically evaluate a case series and, based on common characteristics, hypothesize the mechanism of injury as well as means to prevent it. METHODS Retrospective review of circumcision-related glans amputation cases referred for evaluation and management, focusing on detection of common history and presentation patterns in order to evaluate possible underlying mechanisms. RESULTS A neonatal elective circumcision was conducted using a Mogen clamp and an oblique injury to the ventro-lateral aspect of the glans was noted in 6 cases referred over a 5-year period, suggesting a similar trauma pattern. The urethra was consistently involved. The amputated segments were reattached as free composite grafts in 2/6 cases. Three patients underwent delayed glansplasty months after the trauma in an attempt to restore natural symmetry and cosmesis. In one case a buccal mucosa graft was employed to rebuild the ventral coronal sulcus. CONCLUSIONS Trauma pattern suggests that the ventral glans is at high risk for injury by traction on incompletely released ventral preputial adhesions with subsequent glans entrapment. Practitioners performing neonatal circumcisions, particularly with a Mogen clamp, should exercise adequate release of ventral adhesions to prevent this complication.

A New Grading System for the Management of Antenatal Hydronephrosis

BACKGROUND AND OBJECTIVES Standard clinical assessments do not predict surgical intervention in patients with a moderate degree of upper tract hydronephrosis. This study investigated whether combined measures of renal calyceal dilation and anteroposterior diameter (APD) of the renal pelvis at the first postnatal ultrasound better predict surgical intervention beyond standard assessments of the APD or Society of Fetal Urology (SFU) grading system. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective cohort of 348 children with antenatal hydronephrosis followed from 2003 to 2013 were studied. Using Cox regression, the risk for surgery by APD, SFU, and combined grading on the basis of the first postnatal ultrasound was calculated. The predictive capability of each grading system for surgery was determined by calculating the positive likelihood ratio (LR+). RESULTS The combination of APD≥6-9 mm and diffuse caliectasis had a hazard ratio (HR) of 19.5 (95% confidence interval [95% CI], 3.94 to 96.9) versus 0.59 (95% CI, 0.05 to 6.53) for APD≥6-9 mm alone and a similar risk of 8.9 for SFU grade 3 (95% CI, 3.84 to 20.9). The combination of APD≥9-15 mm and diffuse caliectasis had an HR of 18.7 (95% CI, 4.36 to 80.4) versus 1.75 (95% CI, 0.29 to 10.5) for APD≥9-15 mm alone. The LR+ for surgery for diffuse caliectasis and APD≥6-9 mm was higher than for APD≥6-9 mm alone (HR=2.62; 95% CI, 0.87 to 7.94 versus HR=0.04; 95% CI, 0.01 to 0.32) and was higher for APD≥9-15 mm and diffuse caliectasis than APD≥9-15 mm alone (HR=2.0; 95% CI, 1.15 to 3.45 versus HR=0.14; 95% CI, 0.04 to 0.43). Both combined groups of moderate hydronephrosis (APD≥6-9 mm or ≥9-15 mm with diffuse caliectasis) had only slightly higher LR+ than SFU grade 3 (HR=1.89; 95% CI, 1.17 to 3.05). CONCLUSIONS These results suggest a grading system combining APD and diffuse caliectasis distinguishes those children with moderate degrees of upper tract hydronephrosis that are at higher risk of surgery.

Utility and cost-effectiveness of uroflowmetry in a busy pediatric urology practice.

INTRODUCTION Uroflowmetry (UF) is frequently employed in daily pediatric urology practice for diagnostic and follow-up purposes. We assess the utility and cost-effectiveness of UF in the management of patients seen at a tertiary care centre. METHODS We retrospectively reviewed the charts of consecutive patients who had a UF between January 1, 2010 and March 31, 2010. We collected data on demographics, diagnosis, UF parameters and the impact of the UF on management. The impact on management was defined as indication for surgery, introduction of new medications and bladder retraining based on clinical and UF findings. RESULTS In total, 524 patients were included in the study. In 63 (12%) patients, UF was performed as part of the evaluation at the first clinic appointment. The most common diagnoses were voiding dysfunction (VD) 41%, hypospadias 26%, vesicoureteric reflux (VUR) 16%, monosymptomatic nocturnal enuresis (NE) 8%, posterior urethral valves 5% and meatal stenosis (MS) 4%. In the VD group, UF contributed to a management decision in 25.2% of patients. In the MS group, surgical intervention was based on symptoms and supported by the UF in 41% of patients; in the PUV group, 50% of patients demonstrated high (>20 cc) post-void residual, which aided in management decisions. In contrast, there were virtually no changes in management supported by the UF in the NE, VUR and hypospadias groups. Overall, UF parameters had a direct influence in the management decisions in only 67 (12.8%) patients. Nonetheless, a repeat test was ordered for 44.5% of patients. CONCLUSIONS In an era of financial restraints and in a busy tertiary pediatric urology practice, judicious use of UF for specific indications may translate into a more cost-effective use of time and resources. As expected, patients with VD were the ones that benefited most from the test, as did patients with symptomatic MS and PUV.